Thursday, May 24, 2012

Arua Rural Rotation (13 May - 23 May)

I spent last weekend in Kampala since on Sunday, Renee and I had to leave for our week long rural rotation in Arua - a town in northwestern Uganda near the Congo border. The weekend was pretty quiet. Renee and I went out on Friday night with our housemate Sarah and Lucy - the wonderful woman who runs Edge House. The place we went to was packed and everyone was dancing. Feeling tired from our week, Renee, Sarah, and I were the first to leave the dance party and head home. Saturday morning was lazy as well. I enjoyed sleeping in and relaxing at the Edge House and Makerere Guest House, reading and writing emails. That night we went out to watch football (soccer) at a local pub. We didn't get home early enough for the time we had to get up Sunday morning so the 6am alarm I set was quite unwelcome. Renee and I had a ride coming at 630 to bring us to the bus booking office to book our bus tickets and catch the 730 bus to Arua. It was a bit of an adventure to get our tickets and get on the bus. We were at the booking office by 645 but no one who worked there was around. We sat and waited. The bus to Arua arrived before any of the office workers did. Finally around 710, an office worker arrived and Renee got in line to buy our tickets while I watched our luggage. While she was not making any progress in the line, a man starting yelling "15 minutes until the bus leaves. 15 minutes!" then it was "10 minutes!" then "5 minutes!" Finally Renee made it to the front of the line and as the man was making the final call for bus boarding, we got our tickets, gave our luggage to the guy loading luggage under the bus and took our seats at the back.

The journey was pretty uneventful albeit long and not the most comfortable. It is between 7-8 hours from Kampala to Arua and for a bus ride that long, I definitely do not recommend sitting in the back of the bus. I was tired enough to sleep but too uncomfortable to actually get any meaningful sleep on the road. Every time I seemed to fall asleep, the bus would go over a pothole or one of the many speed bumps and Renee and I would be airborne - not so conducive to sleeping.

We made it to Arua a little before 3 in the afternoon and Renee called Dr. Alex, our supervising doctor for our time in Arua. We waited at the bus station for about 20-30 minutes for him to pick us up and take us to our lodging. Our home for the weeks is pretty nice. We are just outside Arua town adjacent to a golf course. We have a clean and comfortable room although there is only electricity for about 5-6 hours a day and although the shower has hot water, the shower head doesn't exactly work so I have to shower underneath the faucet. The restaurant has good food and we get breakfast so I really have no complaints. And it's cheaper than staying at the Edge House for a week. After getting settled and relaxing for a while on the porch outside our room, we ordered dinner. As soon as we ordered, Dr. Alex called us and said he wanted to take us out somewhere. We paused our dinner order and when we arrived, we discovered he was taking us to the hospital for a quick look. Apparently there was some trauma that was coming in and he was called in. It must not have been much of an emergency if he had time to pick us up before going and when we got there, there were no patients. The "emergency" never came in. We left the hospital and instead of going back to our lodging, Dr. Alex took us to his house where we met his mother and a friend of his. We hung out there and watched television - neither Renee nor I had any idea what was going on. Plus we were getting increasingly hungry and tired. After about a half hour, we got back in the car, this time with Dr. Alex's mother and friend and headed further out of town where we picked up some more people then went to the District Hospital to visit a patient who is somehow connected to Dr. Alex personally. It was interesting to see, but not on a Sunday night and after 8 hours on an uncomfortable bus. The best part about the hospital was when we saw a few cows wandering around on the grounds. After an hour, we finally were brought back to our lodging and had our dinner - fish and chips (French Fries). The fish was literally a whole fish, head, tail and all and Renee had to teach me how to eat it. It was really tasty and definitely welcome after not having eaten much all day. We went to bed exhausted and ready to start a new day at the hospital.

Monday morning we got up and had breakfast at the hotel. We were supposed to be picked up at 830 but didn't end up getting picked up until nearly 9. We were taken to Arua Regional Referral Hospital to the casualty ward. The hospital had a long queue of patients already waiting and the medical and surgical casualty were full. Renee and I met Dr. Alex and got to work seeing patients. It was nice that we had the autonomy to see patients on our own but then staffed our patients with Dr. Alex. It was nice to have the supervision and feedback. I saw a wide variety of pathology - two cases of malaria, several fractures, a late presentation of congestive heart failure due to mitral valve incompetence, a patient with a 16cm spleen due to liver failure and portal hypertension. It was great to get some exposure to things that I either don't see often if at all at home and to see diseases late in their natural course. At the same time, it is sad that those things exist here and although it is great for my medical education, it makes me sad that people do not have equal access to healthcare resources everywhere. The entire country is pretty resource poor so everyone is equal in the lack of resources unlike at home where we have the resources, but unequal access. After all that I have seen this year and working with so many international medical students who come from countries with healthcare systems that equally take care of everyone, I am more convinced than ever that healthcare should be a human right and everyone should have equal access.

I think Renee and I have gotten quite used to Ugandan time and both of us will have to switch back quickly when we get back home. This morning we were supposed to go to the HIV/TB ward for ward rounds which we were told started at 8:00am. We had plans to try and leave between 7:40 and 7:45 to walk to the hospital. We didn't leave our room until about 7:35 and then when we went to have breakfast, the breakfast wasn't ready. We ended up not leaving until a quarter after 8 and made it to the hospital by 8:30. At home, this would certainly not be acceptable. Here, the doctors had not even arrived on the ward yet. Arriving a half an hour late, we still managed to have time to get a complete tour of the ward with an introduction to all the patients before the ward rounds started. It was interesting to see these patients of which we rarely if ever see at home. They are some of the sickest looking patients I have seen so far during my time in Uganda. The worst part was how young most of them were. It's sad to see people my age or younger wasted away from the AIDS and riddled with TB - pulmonary, meningitis, effusions, was all there. The worst patient I saw was on re-treatment for TB after having stopped taking his medicines the first time around. Unfortunately for this patient, he had a severe drug reaction likely to one of the new TB medications causing him to develop horrible bleeding ulcers all over his mouth and gums and his skin to start sloughing off of his feet and legs. This drug reaction can be life threatening and so all TB medications were stopped in an effort to treat his drug reaction. After our morning on these ward rounds, Renee and I decided it was time for lunch before heading back to the casualty ward for the afternoon. When we arrived on the casualty ward, there were no consultants present. There was one nurse who was about to leave for her lunch break and a few nursing students around and that was it. The nurse told us that there was one very sick patient that she thought might have TB and told us to put on masks before we went to see him. Renee and I decided that if we were left alone, we would see patients together because two medical students, even though still not equivalent to one doctor, is better than just one medical student. The moment I saw this patient, I was reminded of the ward where we had spent our morning - he was emaciated, clearly sick, with a cup that was slowly filling with the sputum he was coughing out from his lungs. His BP was low and his heart rate was high so we decided to give him fluid resuscitation. There were no nurses or nursing students around at this point and so I placed the IV line myself. We finished taking his history and doing his exam then went to work on the paperwork to admit him and get him a chest xray, a PPD skin test, and a rapid HIV test. After this first patient, the patients continued to keep on coming. Together Renee and I managed two patients with hypoglycemia, a malaria patient, an acute abdomen, an gangrenous toe with cellulitis, and finally two nursing students who asked for us to consult for them since they were not feeling well. There may have been more, but when things get busy in the casualty ward, I don't always have time to record each patient that I see. The problem also is that the nursing students don't always understand what Renee and I ask them to do. For our two hypoglycemic patients, we gave them both dextrose to treat it. According to my Emergency Medicine Manual, you are to give a 50mL bolus of 50% dextrose then recheck the sugar, and if it's still low, repeat the bolus. The only bags of 50% dextrose we had were 100mL. I drew a line through the middle of the bag and asked the students (who had all appeared when previously when the likely TB/HIV patient was there had disappeared), to watch and stop the drip when the fluid level reached the line. The next time I glanced at those patients, both of them had received the entire 100mL of dextrose. Of course as a result, they went from being hypoglycemic to a not insignificant level of hyperglycemia. At least the body is able to compensate for a transient hyperglycemia better than the hypoglycemia so hopefully there isn't any long term iatrogenic sequelae. The best part about these episodes with both patients is that Renee and I are pretty sure we figured out the underlying cause for the hypoglycemia in the first place - one was probably a medication side effect in combination with not having eaten or drank anything all morning then going out to do physical therapy. The other one most likely has a gastric ulcer - she had not eaten or drank all day and when I asked why she said that for the past month she had stomach pain every time she ate. She also drinks a lot of coffee and was recently on a medication for heart palpitations. This may be the one and only time that I see the initial presentation of a gastric ulcer as a hypoglycemic episode.

After finishing in casualty, Renee and I were invited to dinner at the home of a Minnesota couple (United Methodists from New Ulm) working for the Peace Corps here in Arua. We had a delicious home cooked meal and a delightful time chatting and getting to know this husband and wife pair who have three children all around our ages and decided to join the Peace Corps because "we aren't dead yet." It was nice to be with people having a shared experience of being asked to do things beyond our training and comfort level. It was great to make some new friends. Feeling full after dinner and eating a few local mangoes, we headed back to the hotel very happy and content with our day. We may be extending our stay in Arua for a few days...

After two long and tiring days of working in the hospital, Renee and I decided that Wednesday would be a short day if it was nice and we would leave the hospital around lunch and head to the one and only pool in Arua for the afternoon. The day was beautiful - perfect for relaxing by the pool. At the hospital that morning we went to the pediatric ward to join the pediatric ward rounds. The doctor was later than we were in arriving and he was alone doing the ward rounds that morning. In one room alone, there were 25 patients. In the first hour, we only got through two of them and this was not because there was a lot of teaching happening, it was because of the disorganization of the files and the fact that many of the patients were new or were supposed to have various testing done and there was a search for results or a search in the record to find out why exactly the child was admitted. The consultant had a lot of work to be done and not a lot of time for teaching. After a few hours, Renee and I had figured out that we were not going to get much out of pediatric ward rounds and decided it would be better for us to leave and relax and recharge for the rest of the week. The pool in Arua is fairly small - not great for a pool workout but I attempted to get at least a long warm up in - but it is quiet and very relaxing and the adjacent restaurant had delicious food. Despite our repeat application of sunscreen, we both left the pool burnt after spending more than 6 hours of our afternoon there. I was able to finish my book (Cutting for Stone - great book!) and both of us left feeling much more refreshed.

Thursday we were back at work. We had planned to attend the Under 5 Clinic that morning. On our way there, the Peace Corps nurse from Minnesota caught us and took us around the maternity ward. The nice thing about this maternity ward compared to Mulago is that there are actually curtains between the women so they are not just lying out in the open laboring in front of 20-30 other women. When we arrived at the Under 5 Clinic, there was no doctor there yet and soon we were asked by the Peace Corps nurse to come see a child in casualty who had been referred to Arua from a nearby hospital for severe malaria and anemia and was in bad respiratory distress. The other hospital had told the family that there was nothing that could be done to save the child, but we were asked to take a look and give our opinion. This is definitely not a job for medical students but as again there were no consultants to be found in casualty, Renee and I reluctantly took charge. We put the child on oxygen (miraculously, they had this available in casualty) and started trying to start an IV line and also work to get the child admitted and under the care of the pediatrician who happened to be present on the pediatric ward.

After we sent the child straight away to the pediatric ward, we had two unconscious patients. One I'm pretty sure has tetanus (we were also considering cerebral malaria and bacterial meningitis). She was completely rigid all over including her jaw. Apparently one month ago she was given tetanus toxoid (we couldn't get more history than that) and I'm thinking that as a result of whatever happened at that time, she ended up developing tetanus. The other unconscious patient was in respiratory distress. She had delivered a stillborn baby via cesarean section 5 months ago and had had abdominal pain since that time. We didn't come up with a diagnosis for her (my top concern was a pulmonary embolism) and so we admitted her to the ward. We had a couple of really sick kids with malaria and one with measles. I saw a diabetic patient who I'm pretty sure was in renal failure with a huge amount of fluid retained everywhere - lungs, abdomen, legs. There was one other unconscious adult - Renee and I diagnosed malaria again since it seems that is what everyone had here if they have a fever and some other vague symptom. We saw a patient who was oozing pus out his belly button. His abdomen was tense and tender and he had an abscess in the left lower quadrant. He also had a chronic cough with sputum production and was completely emaciated. He smelled like TB/HIV (literally - it has a smell) and so we admitted him and I'm pretty sure he has HIV and TB and who knows what that abscess is - probably TB. I started a few IV lines including one in a child.

There was one patient that really got to me today that I was concerned about and would have felt responsible had something bad happened to her. It was a young woman in her early 20s who that morning had witnessed her father die in a motor vehicle accident. She was hyperventilating in respiratory distress. She herself was not involved in the accident. Her family was really concerned about her - understandably although we could find nothing physically wrong with her. Renee and I were both pretty sure that she was in a state of mental shock had an acute stress disorder at that moment which was why she was in the state she was in. At the same time she was there, we had several other really sick patients and so she just wasn't a top priority after we ruled out everything serious. She would quiet down for a while and then all of a sudden scream and start hyperventilating again. Apparently she had been seen by someone while Renee and I were out for lunch and had been given "an injection" of something. No one there knew what she had been injected with and there was no note. I was guessing that she had been given diazepam but I didn't know. I asked all the nurses and the clinical officer I found in clinic but none of them had seen this patient and there were no notes or records anywhere for her. We had given her a bag to breathe into but that was also not helping. I decided to give diazepam thinking that the vial only contained 5mg and according to my Medscape reference, you can give 10mg in one dose. So I filled the syringe and quickly checked the vial - diazepam 5mg/mL - and it didn't register until after I gave it to her and she quieted within a minute that the vial contained 2mL - 10mg of diazepam, not 5mg. Again, this would be okay except for the fact that I wasn't sure what "injection" she had been given earlier and if it was diazepam, I had no idea how much had been given. So I was terrified that I would put in her in respiratory arrest and we don't have a ventilator (let alone an ICU) and if she died from respiratory arrest because I OD'd her on diazepam, it would have been all my fault. We had decided to admit her to the psych ward and thankfully by the time she was headed there, she was awake and breathing okay and no longer hyperventilating. That was the most terrified I have been yet for sure in Uganda (it even surpasses being left alone in the surgical casualty at Mulago). It also made me question if what I am doing here is really helping the patients. I wonder if I am actually making a difference for anyone...

The alarm went off Friday morning and as the week has gone on, it has become more and more difficult to get up when the alarm sounds. I laid in bed for an extra 15 minutes before I could get the energy to move. We decided to try and avoid the casualty ward again today and since yesterday was so intense, thought that maybe a half day with the afternoon spent at the pool (in the shade this time) if it was nice outside would be a good idea. It was another beautiful day as we walked to the hospital. When we arrived, we found that again there were no doctors in the Under 5 Clinic so we thought we would try and make our own ward rounds on the patients we had admitted from the day before. If you can imagine, it was really difficult to find our patients. Not only are the wards themselves all in separate buildings and unlabeled, but there is also not often a doctor present or anyone who knows the patients that are on the wards. Plus it didn't help that we didn't have any of the patient names written down - just the diagnoses we had contemplated and the ward we had sent them to. We did find a few of our patients - the woman we thought had tetanus/cerebral malaria/meningitis was actually conscious although she was still rigid and her jaw was still clamped shut. After making our rounds, we decided to see what was happening in the minor operating theater. There were a few procedures that morning that we observed. We saw drainage of a foot abscess, a circumcision on a 1 year-old child, removal of an inguinal lipoma, evacuation of a hematoma, and suturing of a laceration secondary to an assault with a knife. It was pretty interesting although sterile technique here definitely doesn't match the sterile technique either Renee or I was taught at home. The worst of the procedures to watch was the circumcision. There is a big campaign to get men circumcised since research has shown that it can reduce the likelihood of HIV transmission. Unfortunately, most of these circumcisions are done well after birth at an age when the boys or men can remember it happening. This one-year old was supposed to have his circumcision under general anesthesia but because his parents had fed him an hour before, he would have to wait 6 hours for the procedure. At home, I think they would have waited and done it later under general, but here, they decided to just do with local anesthesia and no sedation. They strapped the child down to the table with dad holding down his arms and chest and mom holding down his feet. It was borderline barbaric to watch. The child screamed throughout the procedure and for a while afterwards. Once all the procedures of the morning were done and there were no more patients waiting, Renee and I decided it was a good time to call it a day and head to the pool. We had a beautiful day and I was able to get in a short swim and do some reading and take a nap. It was very relaxing. We are both looking forward to sleeping in this weekend and resting up for our final few days in Arua next week.

The weekend in Arua was pretty quiet. Renee and I enjoyed sleeping in. Saturday was rainy but we managed to make it to the market in between the rains. The market is huge and busy and easy to get lost in. There are a lot of fabrics, clothing (new and used), toiletries, name it, it's probably in the market somewhere. The adjacent food market is also crowded with vendors selling a whole assortment of fruits, vegetables, beans, bread, grains, meats, and the delicacy fried flying ants. The rest of the day was pretty quiet. We read and lounged and then headed to the Indian Restaurant for dinner. After a delicious meal ending in tea, we headed back to the hotel to watch the Premier League championship match. The restaurant was crowded with mostly fans for Chelsea. It was an exciting football match and we went to bed quite late afterwards. Sunday morning we slept in a little then headed to the pool for some lounge time. In the afternoon we went to a dinner party hosted by some of the peace corps volunteers stationed in the West Nile region, including the couple we had dinner with earlier in the week. It was a great day and a very relaxing way to head into our final few days in Arua.

Monday we planned to go to the operation theater but they only operate on Tuesdays, Thursdays, and Fridays in the main theater so we went back to the casualty ward. Dr. Alex was back today after his nearly week long trip to Kampala so there were consultants present in the ED. This seemed to make everything a bit more chaotic as they tried to shuffle patients in and out as fast as possible. Instead of being able to evaluate a patient and consider the diagnoses and management plan, Renee and I mostly ended up just being scribes for the history and physical exam. There was not as much learning because there was not much teaching and we weren't given the time to really consider what we thought might be happening with the patients. Regardless, we saw a variety of pathology including a man with elephantiasis, a woman with a cervical and uterine prolapse, a facial tumor, a throat tumor, TB, infected wounds, and some lacerations that we each got to practice suturing. I sutured my first lip laceration which was good experience. All in all the day was okay but the best part came after we returned from the hospital. During lunch, Renee and I reserved our bus tickets for Wednesday to head back to Kampala. While on our way back from the bus office, we stopped by a sports store and bought a football (soccer ball), a pump, and I got myself a Ugandan Nationals shirt. The football we had played with back at Edge House belonged to some British students who have since left. Renee and I want to start playing again when we get back to Kampala so we bought a ball. We decided to try it out this afternoon and our kicking the ball around was interrupted by a group of young boys heading home after school. They joined us in playing a game where we all stood in a circle and one person was in the middle. The ball was passed around the circle until the person in the middle intercepted it and then whoever lost the ball was the new person in the middle. It was a blast and turned our day from kind of mediocre to really fun. Now we are relaxing again in the evening waiting for a our final day on our rural rotation.

We spent our final day in Arua in the major operating theater. Before going to the theater, Renee and I decided to take pictures of the hospital. Our photo taking continued as we dressed in the very non-matching scrub uniforms that they had us wear for our time in the OT. The surgeons had a variety of operations scheduled. There are two theaters but in general only one is used and the other is reserved for emergency cesarean sections. The surgeons do a bit of everything - general surgery, orthopedics, and ob/gyn surgery. I was impressed by their speed of operating and the room turnover speed as well. They got through the morning's cases very quickly. We saw a variety of operations including two hernia repairs, a cesarean, a thyroidectomy, an appendectomy, and debridement for osteomyelitis. There were a lot of things that were done differently in Arua compared to at home. Like in Haiti, there were a lot of ants and flies in the OT and during the osteomyelitis case, one fly landed on several of the surgical instruments and the surgeon's hand and the surgery continued without spraying the instruments or the surgeon changing the best of circumstances, osteomyelitis is difficult to cure, but here it seems like it may be nearly impossible. This operation seemed like a last effort to get rid of the infection before this 6 year old boy will need to have his leg amputated. Both hernia repairs (epigastric and femoral) were done with local anesthesia only. The surgeons injected lidocaine at the site of the incision and down into the tissues and when the patient cried in pain, they would inject some more. After the surgeries were done, the patient was asked to get up off the table themselves and walk out of the OT. They did use general anesthesia for the thyroidectomy and appendectomy but general anesthesia here is with ether gas and there are no monitoring devices for the anesthesiologist to use to measure heart rate, blood pressure, or oxygen saturation. These measurements were not even taken manually during the surgery. Perhaps the lack of monitoring is part of the reason why they use local anesthesia instead of general for as many cases as possible. The anesthesiologist also did not listen to the chest after intubating the patient either - at least the surgeons operate pretty quickly in the event that the tube was not in the right position... The cesarean was an interesting case. The mother had 4 previous cesareans and this pregnancy was complicated with high blood pressure and placenta previa. Because of all these factors, the baby was delivered at 31 weeks - pretty early especially in a setting where there is no NICU. The baby was only about 3lbs but had a vigorous cry after delivery and seemed to be doing okay. Being premature in a place where so many children die before the age of 5 due to malnutrition, malaria, diarrhea, or respiratory illnesses is really a disadvantage. It's hard to be hopeful in a case like this. The thing that I was most happy about was that the mother consented to a tubal ligation with her cesarean - with a 5th uterine scar, her chances of a uterine rupture if she were to become pregnant again would be quite high.

After the OT, Renee and I had some lunch then went back to the casualty ward one last time. We saw a couple of malaria patients and got them admitted then took some last photos with the staff of Arua Regional Referral Hospital. After we said our goodbyes there, we made one last stop at the home of Marcy and Tom (the peace corps volunteers from Minnesota). Although it was sad to say goodbye, we were both excited to get back to Kampala. Our bus trip Wednesday morning was uneventful except for when we got to the one bridge traversing the Nile that connects the West Nile region to the rest of Uganda. There is a security checkpoint here as a result of the LRA and Joseph Kony and everyone has to get off the bus, show their ID and have their bags searched. It was nice to get off the bus for a few minutes in the middle of our 8 hour bus ride. The funnies part was the sign that pointed out an animal checkpoint. I'm not really sure what they search the animals for, but apparently even animals are not exempt from the security checkpoint. We arrived safely back in Kampala and were able to celebrate with our friends Sarah and Ruth who were leaving that night and the following day, respectively. It is always hard to say goodbye especially to Ruth who had been with us since the beginning of our time in Uganda. It is the friends we have made while sharing these intense experiences that help to keep us sane and to take a step back and still be able to enjoy everyday.

Location:Arua, Uganda

Monday, May 21, 2012

2 Weeks in Surgical Casualty

I spent the past two weeks at Mulago Hospital in the surgical side of the casualty ward. This is similar to the emergency department at home. It is separated into a medical side and a surgical side and is staffed by medicine doctors and surgeons, respectively. I had heard this was a great place to get some practical experience especially with suturing up lacerations. At first I was surprised at how small the ward was. It is made up of several rooms - one is the main treatment room where most of the patients are seen. There are only 4 beds in this room that is divided by a half wall. Then there is a room for ultrasound, a room for xray, a resuscitation room, a plaster room (for orthopedic cases), and an emergency operating theatre. Most of my time on this service I spent in the main treatment room seeing patients.

The casualty ward is a busy place - on some days around 500-600 patients might be seen. The "slower" days average about 300 patients in one day. Despite the small amount of space in the main treatment room, there are a lot of "staff" people crowded in there and unfortunately not many of them are consultant physicians. During my two weeks, I was the only international student on the ward except for one day when my roommate Nicole joined me. There were several paramedical students and nursing students who also often lacked supervision. I often found myself not only in a position where I was without supervision, but I was also the supervision for the paramedical and nursing students. As I had the most knowledge and experience of us students, I was the senior. As a medical student, that is a very terrifying and humbling position to be in. I am very aware of what I don't know and when I need help and to not have anyone to ask when in that position is a horrible feeling. I am getting ahead of myself...

My first day on the ward was quite atypical. It was quiet. I was disappointed because I had heard such great things, and my first day I didn't end up being able to do much. I learned how the paperwork was filled out for patients and was able to suture up one patient's laceration, but that was about it. The next couple of days picked up and soon I was seeing and managing a lot of patients on my own. During this time, there was always at least an intern present for me to ask questions and to have check over my assessment and plan. All this changed on Thursday during my first week. The morning was a typical morning - the usual variety of trauma (mostly motor vehicle accidents), acute abdomens, back pain, swallowed foreign bodies, abscesses - I had lunch and then went back for the afternoon. When I arrived, the only staff present was the intern. There were not many patients in the emergency department and I got started on a new one that had come in. Soon after, a child came in with a femur fracture from a boda boda (motorcycle taxi) accident. The intern glanced at the patient and while I was still in the middle of evaluating the patient I had started on, he said "I haven't had lunch yet. You are okay to handle this, right?" Before I had a chance to answer, he left and I was alone with a couple of paramedical and nursing students. No nurses, no consultants. I was the most senior person there and I was in charge. I finished up what I was doing and went to see the femur fracture child. As I started my evaluation of him, two more trauma patients came in - the father of the child with the femur fracture who also had injuries from the accident and a patient with head trauma, several lacerations on his face and scalp and bleeding from his ear and nose. I was in way over my head and I knew that and was completely uncomfortable. Morally, I couldn't leave. Even though I was being forced to manage things by myself without supervision, I felt a responsibility to be there for the patients and try to do what I could to make sure that no one died. That was my only goal during that 1-2 hours I was alone - to make sure no one died. The paramedical students and nursing students wanted to help, but unfortunately they had so little experience that they needed me to explicitly explain what I needed them to do. It was terrifying having that responsibility. Somehow I managed and no one died and finally after being left alone in charge for 1-2 hours, the intern and one consultant returned. I finished up with the patients that had come in and talked with the consultants about them. It was nearly 5 and since that is when the international office closes and because I was exhausted from the afternoon, I left. The worst part about it is that even though I told both the consultant and the assistant to the international coordinator that I was left alone in charge of the emergency ward, the only response I got was, "Well, that's great for your learning." No. No it is not great for my learning to basically be experimenting on patients. I did what I thought to do and yes, no one died and I think I probably did the right things for these patients, but I should not have been left without supervision. I do not have enough training and these patients deserve better. They deserve to have trained professionals managing their emergencies and not an international medical student on her fourth day on the emergency ward.

This is one of those kind of days that makes me really grateful for the friends that I have and the support network that I have developed while in Uganda. I told my housemates about what happened, and they were so supportive and reassuring and helped me wind down after such an intense experience so that I could face the next day.

On Friday, I made sure to bring my Emergency Medicine Manual in my pocket to the emergency ward. If I wasn't going to have supervision, then at least I would have a text to consult so I had some kind of a teacher. I was very glad that I brought that book and for the rest of my time in emergency, it was my closest friend. Friday morning when I arrived, there were no consultants in the emergency department again. Apparently they were all at a meeting. I walked into a room with a few paramedical and nursing students and three bloody messes. The students were focusing all their time on the least critical of the patients - they saw that patient as an opportunity to learn how to suture. As they approached me to ask if I could supervise them, I asked if they had looked at any of the other patients. They had not. I told them that before I could supervise suturing, I needed to assess and triage the other patients that were there. The patient they were focusing on was stable - no bleeding, okay vitals, although he had amnesia for the event that lead to his coming to the hospital - concerning. The other two were in worse shape. One had several lacerations on his face and scalp and had lost consciousness after he had been in a motor vehicle accident. He had bleeding from his nose and ear and a huge hematoma forming underneath his scalp. The other was the most concerning of all. He had a laceration on his head and an open wound on his ankle and was actively vomiting - a sign of increasing intracranial pressure. Thankfully I was not alone for long before the consultants returned from their meeting and I could relax a little and just focus on one patient instead of three.

Mulago is the National Referral Hospital and so cases from all over the country are brought here when they have surpassed the expertise or resources of the smaller district and regional hospitals. It also is the regional hospital for Kampala and so a wide variety of pathology is seen on the wards. Although the surgical casualty wards tends to see a lot of trauma patients, a fair number of other interesting things walk through the door as well. I saw one woman who had a suspected meningioma for the past ten years. One entire side of her face was puffed out from the tumor. Because they don't have any treatment available for her, her tumor just keeps growing. It seems we get a lot of late presentations of cancers. The patients don't seem to come in until something has really advanced and so we see some huge masses or patients who are wasted away from throat cancers who haven't been able to eat for months. We also see a lot of bread and butter emergency room problems as well - I saw many young children who had swallowed coins or batteries or some other object and acute abdomens. The trauma patients often seem to involve boda boda accidents. The worst of these involved three people on the same boda - the driver, an older woman, and her grandchild. All three of the boda riders had right sided mid shaft femur fractures. The older woman also had a right sided humerus fracture. Both the driver and the grandchild had open fractures - the driver's fracture had a huge piece of skin missing and a large hematoma had already formed above the fracture site. All of the fractures are set in the casualty ward before they are moved to the wards. Depending on who is working in the plaster (ortho) room, the patients get varying amounts of analgesic relief before manipulation of their fractures. One orthopedist was really great and made sure all patients had morphine on board before reducing and setting the fractures. Others will do the manipulation when the patient has only received diclofenac (an NSAID like ibuprofen) - you know when these patients are being reduced because their screams reverberate throughout the entire third floor of Mulago.

It isn't just with ortho manipulations that pain management often seems a bit lacking. I saw one woman with a peritonsillar abscess. The casualty physician stuck a scalpel blade on the end of a clamp and was poking at the abscess at the back of her throat to try and drain it. I have seen a lot of kids with abscesses. It doesn't seem to matter how old the child is or where the abscess is located, they are all drained in the emergency ward without any sedation and sometimes not even local anesthesia. It's also hard to watch the parents have to pin their children down in order to keep them still so that their abscesses can be drained.

The other difficult thing about having so much responsibility for making treatment and management decisions is that I am not really sure what resources are available. Many of my boda accident patients, I have wanted to get a head CT on because I was concerned about intracranial hemorrhages. Of the several that I ordered, I don't really know how many of them were actually done. I found out that there is only one neurosurgeon at Mulago Hospital so even if there was a CT done and it showed a hemorrhage, there isn't a guarantee that a patient would be able to have burr holes drilled in the event of increased intracranial pressure anyway.

The lack of readily available CT is also a problem for other patients. I spent one morning/afternoon in the resuscitation room where a man was brought in. His initial complaint was an acute abdomen and he soon became non-responsive. Initially the physicians taking care of him thought that he had a ruptured spleen - there was some story about an accident/fall and after an ultrasound, there was free fluid seen in the peritoneum and so splenic rupture was suspected. We started rapid resuscitation measures but his blood pressure just wouldn't pick up. He was taken to surgery (relatively quickly - maybe an hour or two after being in the resuscitation room) for an emergency laparotomy. When the abdomen was opened up, the surgeons were surprised to find not blood but intestinal fluid filling up the abdominal cavity. The patient had a perforated ulcer, not a ruptured spleen and was likely in septic, not hemorrhagic, shock. Looking at the records after this discovery, we saw that this accident had happened over a week ago. The patient survived the surgery but died later that night. Had the diagnoses been known (better imaging would have helped improve the odds of making a correct diagnosis), the patient would have not had surgery immediately, but would have been treated more conservatively with antibiotics and measures to increase his blood pressure before being taken to surgery to repair the hole in his stomach.

Despite the challenges and difficulties of working in casualty, I have become even more sure that emergency medicine is the right field for me. I enjoy the fast pace and the variety of patients that I see. I enjoy the hands on aspect - I have lost count of the number of patients I have sutured. I also think it is a great opportunity to do teaching to improve the care that people get when they come to the casualty ward and therefore improve their outcomes. It's the kind of teaching that you can do to enable the people already here to help make the hospitals less dependent on foreign aid.

Location:Kampala, Uganda

Sunday, May 13, 2012

The First 3 Weeks - Outside Mulago

Uganda so far has been the best overall experience. As you probably gathered from my blog about my Ob/Gyn rotation, I am getting incredible hospital experience both in knowledge and practical skills. I also have had a great time with all the wonderful people I met while living here and have had a blast hanging out in Kampala as well as doing some traveling in Uganda.

The Edge House where I live is a busy place. It is usually always full and it doesn't take long after one person leaves before a new one arrives to take their place. Most people tend to stay for anywhere from 4-6 weeks so I will for sure completely switch groups of people in the house once if not twice. The best part is that a few days after I arrived, a girl from the Netherlands (Renee) came and she will be here for the same amount of time that I am. We seem to get along well personality wise and I am excited for the adventures we will have while in Uganda. As I write this, there are 6 people that have already left the house (not including people I met that stayed elsewhere and have left) and another 7+ that will leave at the end of this week. I have had an amazing time with the people I have met the first quarter of my trip and anticipate that each group that comes next will be just as great.

Edge House is definitely the best house. We hang out a lot together and the people that run it - Freddie, Nassa, and Lucy - are fantastic. They even do our dishes for us :) At least a few times a week we go out to dinner together and whenever anyone leaves, the whole house is really good about going out together for a final farewell dinner. Someone always has an idea of a new place to try so I have had Ugandan, Indian, Chinese, Italian, Mexican, and "continental" cuisine. If someone hears about something cool happening on a night in Kampala, they will write a note on a white board that we have and usually there will be a group of people that will go. We went to the contemporary national ballet at the National Theater one night followed by a poetry and hip hop cultural night. I've watched soccer matches on a giant screen at a bar/restaurant called Mish Mash. I've had a massage at the nearby country club and spent two afternoons by the pool. Just last night I went to the Dutch Queen's Party - who knew there were so many Dutch people living in Uganda! I also went to a house party of one of the residents from the UK that I met on rotation with 8 of my housemates. The house party was the coolest house party I think I have ever been to - they had a DJ and a rolex man. Rolexes are great Ugandan street food - a chapati with an omlette rolled up inside (hence the name rolex). We also play games together as a house. We have had a few nights of playing cards, one game of ultimate frisbee, and 2 soccer matches. I don't mind sharing a room and a bathroom and a kitchen and common area with so many people because all the people are really fun to be around. But you can see why I have had a hard time finding time to blog with everything happening around me!

It's nice to know that I have met such great people while living here that in the event that anything bad happened, I know I would have a houseful of people that would be by my side the entire time. I know this because of an incident we had during our ultimate frisbee game. We were having a great time playing. The score was close and so we were all getting a little competitive. One of the girls on my team was going to catch a pass when a girl from the opposing team tried to block it. She ended up sliding into the girl from my team. The game immediately stopped and we all ran over to see my roommate lying on the ground in pain holding her leg with her ankle clearly dislocated and likely broken. Although the hospital is a great experience as a student, it is not a place I would choose to go to as a patient if I could help it. Everyone playing went on a mission - one called our international student coordinator to figure out what hospital to take our friend to, one went to get her money, ID, insurance information, one went to get transport to take her to the hospital, one got some pain medication that she had brought with her. The whole house came together to help one of our own. On the ride to the hospital, there were 4 of us in the van with her trying to get her leg still. Once at the hospital, 3 more of our housemates came to join us bringing more personal items for our injured friend and money in case we didn't have enough to cover the bill. It was really inspiring to see this international group of students who hadn't known each other for that long really rally together to support our friend in need. She ended up staying in the hospital overnight and then saw some Italian orthopedic surgeons in Kampala. The decision was made for her to fly home to have surgery. She has since had her surgery and is doing well at home. We all miss her and wish she was still here with us!

I have had three weekends in Uganda since I arrived and have traveled for two of those weekends. My first full weekend here, I went with a group of British students from Birmingham, Renee from the Netherlands, and Audrey - an American medical student I met on my Ob rotation to Jinja to go white water rafting down the Nile River. The source of the Nile is Lake Victoria and the start of the Nile is full of amazing rapids all the way up to class 6 (the highest class). We rafted 2 class 5 rapids and smaller ones as well. Apparently there used to be a lot more rapids and these rafting trips started closer to the source but in the past few years, a dam was built that has destroyed some of the rapids closer to the source. We were picked up on Satuday morning and drove to Jinja. At Nalubale headquarters, we were fed a breakfast of rolexes, bananas, and juice and were fitted for helmets and lifejackets. We then boarded a truck to head to our launch site. Once we arrived at the launch site, we were separated into two groups - one that was going to have the ultra super extreme rafting trip and another one that was slightly more tame. I, of course, wanting to get the full Ugandan experience immediately walked over to the ultra super extreme raft along with 4 of the 5 guys that were with us and 2 other girls. Our guide was from Zimbabwe and had been rafting for the past 15 years on various rivers throughout Africa and Europe. We entered the Nile at a wide calm spot to learn a few things about rafting before starting our trip down the rapids. Our leader taught us the different commands he would give for paddling forwards and backwards and how to keep in rhythm while paddling. He taught us how to "GET DOWN!" and hold on to the raft when we hit the major rapids. We practiced our short swimmer rescues and how to get ourselves back into the raft. We learned what to do in the event that we became long swimmers (too far from the raft to grab onto the rope on the side) and how to hang on to rescue kayaks properly. We were taught to fold up into a small ball when under the water to facilitate being shot back up to the surface more quickly and then once on the surface to back float with your head looking in the direction you were flowing with the current. Finally we practiced what to do when the raft flipped over. We were told to try our best to hang onto the paddle even when thrown off the raft and given some tips on swimming while holding the paddle. Feeling slightly more prepared, we started off.

The first rapid we hit was a grade 5 and it was a drop down a waterfall. Our leader told us that we really, really didn't want to flip on this rapid. We hit it just right and went over the falls landing with a big splash and paddled our way out of the falls. We watched as the second group went over. They didn't hit it quite as well as we had and ended up partially stuck under the falls and needed the safety boat to throw them a rope and help pull them out from the falls. We continued down the river and the next rapid we hit was a grade 3. We thought we were doing really well paddling through it and then we flipped. We were all a bit suspicious that our raft leader had something to do with our flip. This was confirmed after watching the video and seeing the photos from the rafting trip that indeed we were sabotaged. This set the precedence for the rest of the rafting trip. Except for the very first grade 5 (we had a second one later on in the trip called "The Bad Place") and one other rapid that was only a grade 3 but had some treacherous rocks that the current was directed towards, I was out of the raft on every other rapid...something like 5 or so rapids. Outside of the two where no one fell out, there was only one other rapid that the whole raft didn't turn over on although I was not one of the ones who managed to stay in the raft. It was a blast! I never once felt unsafe. The rescue kayakers were great at getting to you quickly when you became a long swimmer and brought you back to the raft. Even when I was under the rapid, I had a great time being tossed around by the Nile. I folded myself into a ball and got shot up to the surface relatively quickly although at The Bad Place, I was just sucked back under after getting a good breath of air. Our leader definitely lived up to the ultra super extreme rafting experience as he took us down the path of each rapid that would most likely wind up with our raft flipping and if that didn't do it, he flipped us himself. The final rapid called The Nile Special was great fun - I ended up out of the raft near the start and riding it the whole way down. I swam to our raft far downriver.

In between the rapids, we took our time in the slower moving water and swam in the Nile, reapplied sunscreen, and drank some water. We also had a lunch break midday with a delicious sandwich, chips and guacamole, and pineapple. That night we stayed at the Nile River Camp which was a great lodging along the banks of the Nile River. The best part about it was the rope swing that you could swing into the Nile from. That and the hot showers. After a good night of sleep, the next day we went into Jinja and to see the actual source of the Nile. We had heard/read that it wasn't all that impressive, but I thought it was still really cool to see where this famed river originates. The town of Jinja (the second largest in Uganda) was pretty sleepy on that Sunday afternoon but still very pleasant to walk around. After seeing the source and walking around Jinja, we returned to Nile River Camp and took the busy back to Kampala. It was a great first weekend in Uganda.

The following weekend, Renee (my roommate from the Netherlands who is here the entire time I am), Audrey (from Seattle - arrive the same time I did and is staying for 5 weeks) and I took the bus from Kampala to Sipi Falls in eastern Uganda near Mt. Elgon, the highest peak in Uganda and near the Kenyan border. We had heard that the falls were really beautiful and the weekend very relaxing and peaceful. We had a bit of an adventure to get there. We left the hospital early to try and get an early afternoon bus to Mbale but the buses were full until 5:30. The drive to Mbale takes at least 4 hours and sometimes as many as 6 hours and then from there, it is another hour by private hire to the town of Sipi Falls. While waiting for the bus, we had a nice lunch in Kampala City Center. The bus trip took about 5 hours and we arrived in Mbale at 10:30 at night. We had not arranged for any transportation to meet us in Mbale and along the route, the manager of the lodging we were planning to stay at kept calling me to see where we were on our journey. Thankfully, the people from the Mt. Elgon Flyer bus service in Mbale were able to help find us a private hire to take us to Sipi Falls. We finally arrived around 11:30 at the Crow's Nest - a place with supposedly a gorgeous view (which we couldn't see because it was dark) and a bit rustic. They use a generator that they only run for certain hours of the day so we had kerosene lanterns to light our way to our dorm room and for light as we got settled and ready for bed.

The following morning, we were not disappointed seeing the view from outside our dorm. We were on a hill overlooking a valley and Sipi Falls. It was breathtaking and so quiet and peaceful. We ordered our breakfast (it takes a while to get it after you've ordered) and got ready for the day. We arranged for a guide from the Crow's Nest to take us on the long hike through the village, farmlands, and hills to the three waterfalls. Seeing the rural way of life in Uganda was so nice. Most people farm and one of the major crops in this region is coffee. I had no idea that coffee beans on the tree are actually encased in a red shell and look a bit like berries. The hike, despite being at a relatively leisurely pace, still made all of us slightly out of breath due to the altitude. It was nice to take breaks and be able to take in the view from the tops of the hills we were climbing. About halfway through our long hike, it started to rain. Thankfully we all had rain jackets with us as the rain became progressively harder and everything not covered by the rain jacket was soaked. In many ways, this made the hike even more fun. The top waterfall was the smallest of the three but still very nice. There was a "swimming pool" at the base of it but because we were already pretty cold and it didn't look all that inviting, we decided not to get in. The second falls was probably my favorite. We started at the top of it then hiked down to the bottom. There were two parts of this set of falls - the main waterfall and an adjacent one called the "shower." I was glad I had my waterproof/shockproof/freezeproof camera with me to take with us as we stood underneath the shower and got some great pictures of the three of us. Finally we hiked to see Sipi Falls itself - a 99m high waterfall that drops down amongst a background of such lush greenery. It was serene.

After our hike back to the Crow's Nest, we were all glad to change into some dry clothing. We went up to the main lodge to read, relax, and hang out before our dinner (which we had ordered that morning) that we had planned for 6:30. Dinner was delicious and after that we played a card game that Renee taught us - a Dutch game called "Beste" (not sure of the spelling). Renee and I are both quite competitive and especially, I think, with each other when we play games. (It is a friendly, but serious competition between us - we both really like to win). A fourth person staying at the Crow's Nest asked to join in our game so the 4 of us played. To win the game, you have to win 5 rounds. Renee and I were neck and neck the entire evening while Audrey and our new friend were sitting with only having won about 1 round each. I ended up winning the game overall :) We went to bed that night relatively early because without electricity, there is not much to do.

Sunday morning, we got up and met our guide for our planned coffee tour. We went to the home of a local coffee producer and learned the art of making coffee. Starting from the red encased beans, we broke these open to expose the two pale coffee beans inside. These had to be placed in a large mortar and pestle and ground until the coating came off of these beans. Then this was emptied onto a plate and the beans separated from the coating by blowing gently on them. After this, the beans were placed in a pot and put over a fire for roasting. While constantly stirring, we waited to hear the crackle of the beans indicating that they were finished roasting. These were then emptied back onto the plate and we sampled our freshly roasted beans - delicious! The roasted beans went back into the mortar and pestle and were ground up manually in order that we could make coffee. After grinding the beans, the coffee grounds were placed in a pot of boiling water over the fire and boiled for several minutes. Then this was poured through a strainer into a flask for us to drink out of. It was probably the best cup of coffee I have ever had. The flavor was so rich and bold. Coffee lovers everywhere really should go through this process to have the freshest tasting coffee. Amazing.

We went back to the lodge and arrange for a private hire to take us back to Mbale so we could catch the bus back to Kampala. The ride home was much quicker than the ride there and we got back in the early evening ready to start another week at Mulago.

The third weekend (right after my last week on Ob), Renee and I spent in Kampala. A few of our housemates were leaving that weekend to go back home and since we had traveled the previous two weekends and were going to be here for a while still, we decided a quiet weekend was in order. On Friday night, I had been invited to a house party of the the Ob/Gyn resident from the UK that I had been working with on the wards. She told me that all my housemates were welcome to come as well. I wasn't sure what the house party would be like and I was nervous that it would be a total bust especially because I wasn't really sure where it was and it took a while to get a hold of my friend for better directions while we were on the road. We finally made it, and the house was full of people. It was probably the best house party I have ever been to - the house was very nice and they had hired a DJ as well as a rolex man (a rolex is a chapati with an omlette rolled up inside - a Ugandan street food favorite). All the beverages were also provided. We had a blast dancing and making new friends and didn't end up coming back home until the early hours of Saturday morning. Saturday morning, Nicole - one of my roommates returned from her rural rotation. We had a lazy Saturday sitting at the Makerere Guest House using the internet and just relaxing. On Sunday, Nicole, Renee, me, and Sarah (a new arrival to Edge House) went to Kabira Country Club to spend the afternoon at the pool. Although it is a little pricey, it is a great pool to swim in and lounge by and they have really great food. In addition to hanging out by the pool, Nicole and I decided to get hour-long massages (only $10!!). It was a good massage but definitely the most full body massage I have ever experienced. I don't know that I will have another while I am here, but the one time experience was very relaxing.

So that pretty much sums up the first three weeks and as I am writing this and have been in Uganda for 5 weeks, I have a lot more to catch up on in more recent blogs. I hope to write about my experience on the Surgical Casualty ward and my safari to Murchison Falls by the end of this weekend!

Location:Kampala, Jinja, and Sipi Falls